The Diagnosis of Anger as a Presenting Complaint in Outpatient Medical Settings

Anger is a common emotion that can be distressing and damaging to an individual’s subjective sense of well-being, biological health, and interpersonal relationships (1–3). Emotion theorists (4,5) and researchers (6,7) consider anger one of the basic emotions experienced in every culture and at every developmental stage. Although anger is frequent in community (8–10) and clinical settings (11) and can constitute an independent psychiatric problem (12), there is no diagnosis for pathological anger in the DSM-IV-TR (13). As a result, patients with a presenting complaint of anger may receive an inaccurate or misleading diagnosis or even no diagnosis at all. Clearly, each scenario has the potential for clinical harm.

In the only study examining how clinicians might diagnose anger (11), experienced psychologists and psychiatrists were provided with one of two case vignettes illustrating a patient presenting with complaints of anxiety or anger and were asked to make a diagnosis. Although the cases were matched for symptom severity, chronicity, and amount of information, clinicians rated the anger case as having less information and as representing an individual who was less psychologically functional than the individual represented in the case with anxiety. They also rated their confidence in the diagnosis of the anger case significantly lower compared with their confidence in the diagnosis of the anxiety case (11).

If experienced mental health clinicians are unclear about how to diagnose anger as a presenting complaint in a vignette format, diagnosis of actual patients in outpatient medical settings may be more problematic. This study aimed to determine how a presenting complaint of anger was diagnosed in a nationally representative database of office-based and outpatient medical visits. It is hoped that this study may provide a vital contribution to the extremely limited understanding of how anger is currently diagnosed in practice settings on a national level.

Methods

The study used combined data from the 1998–2008 National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS). The NAMCS and NHAMCS are nationally representative of visits to physicians in office-based and outpatient department practices and are conducted annually by the National Center for Health Statistics (www.cdc.gov/nchs/ahcd.htm).

There were 1,005,628 visits included in the combined 1998–2008 NAMCS and NHAMCS databases. Physicians report up to three of the patient’s presenting complaints or reasons for the visit. Primary, secondary, and tertiary reasons for visits are combined to increase sample size. Two reason-for-visit codes included in the NAMCS and the NHAMCS—anger (bitterness and hostile feelings) and temper problems (blowing up, fussiness, irritability, losing temper, and temper tantrums)—were combined to create a subset of visits by individuals presenting with “pathological anger.” Visits by individuals with presenting complaints of behavioral aggression were not included in the sample. Over the ten years included in the analysis, 2,685 visits were coded with a presenting problem of anger. After limiting the sample to adults ages 18 and older, 1,146 visits were included.

The diagnoses recorded for each visit were coded by using the International Statistical Classification of Diseases and Related Health Problems, Ninth Revision, Clinical Modification (ICD−9-CM) (14). Psychiatric diagnoses were categorized as mood (296.0–296.9, 300.4, or 311), anxiety (300.0–300.3 or 309.81), psychotic (295.0–295.9 or 298.0–298.9), or other (301.0–301.9, 304.0–304.9, 305.0–305.9, 312.30–312.39, 314.00, or 314.01) disorders. Of note, the number of intermittent explosive disorder diagnoses was negligible. Last, the diagnoses were classified on the basis of whether they were described as “unspecified,” which corresponds to “not otherwise specified,” “unspecified,” “not elsewhere classified,” or “other.”

Patient sex, age, race (Caucasian or African American), ethnicity (Hispanic), insurance type (Medicare, Medicaid, private insurance, and uninsured status), region of the country and year of visit were examined. Although the NHAMCS does not record data on physician specialty in outpatient medical settings, the NAMCS does record these data (primary care physicians are defined as those in family or general practice, internal medicine, and obstetrics and gynecology). Approximately 86% of visits in the NAMCS subsample in which the clinician recorded a presenting complaint of anger were to psychiatrists. Thus, in office-based medical settings, anger was recognized and recorded much more frequently by psychiatrists than by primary care physicians.

The NCHS weights visits in the NAMCS and the NHAMCS to ensure nationally representative estimates and to calculate 95% confidence intervals [CIs] that incorporate the complex sampling design. Given that this strategy confers large standard errors, p<.1 was used as a measure of statistical significance for all multivariate analyses. To account for the complex sampling design and to ensure nationally representative estimates, the survey procedures of the Stata 2010 statistical software package were used.

Results

The weighted prevalence of anger as a presenting complaint for visits by adults in office-based and outpatient settings was .14% (CI=.001–.002). The weighted prevalence of anger as a presenting complaint among visits to psychiatrists was 4.0% (CI=.030–.049.

Select patient-level factors were associated with presenting with a complaint of anger. Compared with visits by blacks, visits by whites had nearly two times greater odds that anger was the presenting complaint (OR=1.92, p<.001). The odds that anger was the presenting complaint were significantly greater among men than women (OR=1.56, p<.001). Uninsured individuals and those with Medicaid had significantly higher odds than individuals with private insurance of presenting with anger (OR=2.55, p<.001, and OR=1.43, p=.065, respectively). The odds of presenting with anger were significantly greater among all other age groups of adults than among adults ages 65 and over (18–24, OR=6.85, p<.001; 25–34, OR=4.91, p<.001; 35–44, OR=6.03, p<.001; 45–54, OR=5.06, p<.001; and 55–64, OR=2.96, p<.001). [Tables presenting demographic characteristics of the sample and predictors of anger as a presenting complaint are available online as a data supplement to this report.]

Eighty-four percent of visits by adults seeking treatment for anger were assigned a psychiatric diagnosis (Table 1). Among these diagnoses, 44% were classified as not otherwise specified, and 59.1% were mood disorders; 20.1%, other disorders; 16.3%, anxiety; and 4.5%, psychotic disorders.

Discussion

This study aimed to examine the diagnoses given to adults with a presenting complaint of anger during visits to office-based and outpatient medical settings. Overall, anger was rarely a presenting problem in outpatient medical settings. In contrast, previous research has suggested that anger is relatively common in community and clinical, especially mental health, settings. This discrepancy may be explained when one considers that currently DSM has no diagnosis for anger. Given the low rates of detection of better-conceptualized emotional problems, such as depression, in primary care settings (15), physicians in practice settings may be even less likely to record a symptom for which there is no recognized diagnosis. As a consequence, many individuals who experience pathological anger may not be detected.

Visits by Caucasians, men, uninsured individuals, Medicaid recipients, and younger individuals were significantly associated with a presenting complaint of anger. Given that these subgroups are traditionally less likely to seek treatment, these individuals may represent subgroups of the sample with greater severity of anger. If this assumption is true, it may suggest that rates of treatment seeking for anger are low and occur only if the severity of anger is great. However, these assumptions should be tested in future research.

Most patients (nearly 85%) who reported anger as a presenting complaint were diagnosed as having at least one psychiatric diagnosis. This finding suggests that health care providers in practice settings see anger as a distressing problem and an impairment—a finding that is consistent with previous literature (11).

However, several findings suggested a lack of consistency and specificity in the diagnostic protocol for individuals with a presenting complaint of anger. Regarding consistency, mood disorders were the most frequent diagnosis of persons with a presenting complaint of anger (59.1%), despite the fact that the analysis controlled for depressive symptoms. This finding suggests that over half of patients presenting with anger and without depressive symptoms were diagnosed as having a mood disorder. The finding that mood disorders are the modal diagnoses for patients presenting with anger may be explained by the fact that these diagnoses are highly prevalent in outpatient medical settings among persons with emotional problems (15) and they commonly present as irritability or agitation (13).

Minimal agreement was found regarding the remaining diagnoses. The next highest category of diagnoses was “other.” Given that the “other” category consists of many diagnoses, ranging from substance abuse to personality disorders, this finding also suggests a lack of consistency in diagnosis when anger is the presenting complaint. Regarding the lack of specificity of the diagnoses when anger was the presenting complaint, nearly half of all diagnoses were designated as not otherwise specified.

Taken together, patients who presented with a complaint of anger were likely to receive a psychiatric diagnosis even when the symptoms of that diagnosis were not present. In addition, the consistency of the diagnoses given was low. These findings are consistent with previous findings of problematic patterns in the diagnosis of anger as a presenting complaint in specialty mental health settings (11).

This study informs both clinical practice and mental health policy. Perhaps the most important implication of the study is the finding that presenting with a complaint of anger in health care settings was associated with diagnostic inconsistency and lack of specificity. Taken together with previous literature, this study highlights the uncertainty about the appropriate protocol for diagnosis of a presenting complaint of anger.

These practices may constitute a pattern of inappropriate psychiatric diagnoses that in turn may lead to inappropriate treatment and poor clinical outcomes. For example, someone who presents with anger might be diagnosed as having a psychotic disorder in the absence of psychotic symptoms. This could lead to treatment with antipsychotic medication, which would be unlikely to be effective and could result in severe side effects, such as metabolic syndrome or tardive dyskinesia.

Given that this study is the first to document the diagnostic patterns of pathological anger in outpatient medical settings, an intensification of research regarding the diagnosis and treatment of the pathological nature of anger is warranted. In particular, more data could be collected regarding the distress and impairment associated with pathological anger, the influence of patient-level factors on diagnosis to illuminate any disparities in diagnosis, treatment patterns in practice settings, and the economic burden of anger in health care settings.

Ultimately, patients who experience pathological anger deserve adequate diagnosis and treatment. This study suggests that diagnostic inconsistency may be an obstacle toward this goal; thus future research is desperately needed to make the case that anger is indeed inadequately treated on a national level. Should this be the case, the inclusion of an anger disorder in the DSM should be considered.

The results of this study must be considered in the context of the limitations of the data. An important characteristic of this data set is that the unit of analysis was a visit rather than patients. This implies that all results should be interpreted with the understanding that the sample comprised persons seeking treatment, suggesting that their anger was severe enough to seek treatment and report to a physician. Another limitation was the lack of ability to stratify diagnostic outcomes by physician specialty (primary care versus psychiatry) with the full sample, given that only the NAMCS records data for physician specialty.

Additionally, the NAMCS and the NHAMCS record only three diagnoses and three patient presenting complaints. Thus, if an anger-related diagnosis or reason for visit was present but not among the top three recorded, it would not have been available for analysis. In addition, physicians—not patients—report the presenting complaints and diagnoses. Thus the prevalence of anger in the sample may be an underestimate, given the reliance on physician detection. Notably, the patient may have reported anger as a complaint, but the physician did not record it.

An important limitation to the interpretation of the results was the lack of data regarding the severity of the anger presented by the sampled patients. Given that individuals with behavioral aggression were not included, the sample may have represented patients with high levels of anger but low levels of aggression, or “anger-in” (1).

Conclusions

Consistent with previous literature, this study showed a degree of diagnostic inconsistency and lack of specificity regarding anger. The lack of an agreed-upon DSM anger diagnosis is likely the ultimate cause of this problem. It is the responsibility of researchers and leaders in the field of mental health to better understand an emotional problem that historically has been forgotten.